Attributable mortality due to nosocomial sepsis in Brazilian hospitals: a case-control study

Abstract

Background: Nosocomial sepsis is a major healthcare issue, but there are few data on estimates of its attributable mortality. We aimed to estimate attributable mortality fraction (AF) due to nosocomial sepsis.

Methods: Matched 1:1 case-control study in 37 hospitals in Brazil. Hospitalized patients in participating hospitals were included. Cases were hospital non-survivors and controls were hospital survivors, which were matched by admission type and date of discharge. Exposure was defined as occurrence of nosocomial sepsis, defined as antibiotic prescription plus presence of organ dysfunction attributed to sepsis without an alternative reason for organ failure; alternative definitions were explored. Main outcome measurement was nosocomial sepsis-attributable fractions, estimated using inversed-weight probabilities methods using generalized mixed model considering time-dependency of sepsis occurrence.

Results: 3588 patients from 37 hospitals were included. Mean age was 63 years and 48.8% were female at birth. 470 sepsis episodes occurred in 388 patients (311 in cases and 77 in control group), with pneumonia being the most common source of infection (44.3%). Average AF for sepsis mortality was 0.076 (95% CI 0.068-0.084) for medical admissions; 0.043 (95% CI 0.032-0.055) for elective surgical admissions; and 0.036 (95% CI 0.017-0.055) for emergency surgeries. In a time-dependent analysis, AF for sepsis rose linearly for medical admissions, reaching close to 0.12 on day 28; AF plateaued earlier for other admission types (0.04 for elective surgery and 0.07 for urgent surgery). Alternative sepsis definitions yield different estimates.

Conclusion: The impact of nosocomial sepsis on outcome is more pronounced in medical admissions and tends to increase over time. The results, however, are sensitive to sepsis definitions.

Keywords: Attributable mortality; Epidemiology; Sepsis.

Fig. 1

Organ failure at diagnosis in A all septic patients, B pneumonia, C not pneumonia. Each dot represents intersections, with the number of cases shown in bars

Fig. 2

Distribution of odds ratio (upper row) and AF (lower row) according to admission type (columns). The odds ratio should be interpreted as the odds ratio of dying up to a specific day (x-axis) given that the patient has acquired sepsis

Fig. 3

Comparison of the three definitions for medical admissions. Upper panel: the daily odds ratio for mortality in medical patients according to the definition used. Bottom panel: the respective AF for each definition. Note that a higher OR does not equal higher AF due to changes in prevalence